Socially-supportive norms and mutual aid of people who use opioids: An analysis of Reddit during the initial COVID-19 pandemic

Abstract

Background

Big events (i.e., unique historical disruptions) like the COVID-19 epidemic and its associated period of social distancing can transform social structures, social interactions, and social norms. Social distancing rules and the fear of infection have greatly reduced face-to-face interactions, increased loneliness, reduced ties to helping institutions, and may also have disrupted the opioid use behaviors of people who use drugs. This research used Reddit to examine the impact of COVID-19 on the social networks and social processes of people who use opioids.

Methods

Data were collected from the social media forum, Reddit.com. At the beginning of the COVID-19 pandemic in the U.S. (March 5, 2020, to May 13, 2020), 2,000 Reddit posts were collected from the two most popular opioid subreddits (r/OpiatesRecovery, r/Opiates). Posts were reviewed for relevance to COVID-19 and opioid use resulting in a final sample of 300. Thematic analysis was guided by the Big Events framework.

Results

The COVID-19 pandemic was found to create changes in the social networks and daily lives among persons who use opioids. Adaptions to these changes shifted social networks leading to robust social support and mutual aid on Reddit, including sharing and seeking advice on facing withdrawal, dealing with isolation, managing cravings, and accessing recovery resources.

Conclusions

Reddit provided an important source of social support and mutual aid for persons who use opioids. Findings indicate online social support networks are beneficial to persons who use opioids, particularly during big events where isolation from other social support resources may occur.

1. Introduction

There is significant concern regarding how the social disruption caused by the COVID-19 pandemic of 2020 is affecting people who use drugs (PWUD) and those on medications for opioid use disorder (Khatri and Perrone, 2020; Volkow, 2020; Welle-Strand et al., 2020). Previous crises such as Hurricane Sandy in the northeast U.S., the economic strain in Greece, and other complex emergencies have affected access to social and medical services for PWUD, reduced the availability of jobs and other income sources, impeded access to illicit drugs and treatment, and caused serious disruption to social networks (Hankins et al., 2002; Nikolopoulos et al., 2015; Pouget et al., 2015; Strathdee et al., 2006). For PWUD, social networks are critical sources of encouragement and knowledge for safe drug and sexual practices (Friedman et al., 2007; Latkin et al., 2003) and remission (recovery capital; Cloud and Granfield, 2008).

Social networks, the network of social relations and interactions an individual is embedded in, play an important role in substance use behaviors and treatment engagement. Social factors are critically related to opioid use with opioid overdose mortalities conceptualized as “deaths as despair” (Friedman et al., 2020a,b) and opioid systems affected by social network factors (Eitan et al., 2017). Research in animal models has demonstrated social isolation to be associated with increased administration of opioids (Eitan et al., 2017). Evidence from both human and animal research indicates drug-using peers exert a strong influence on opioid-use behaviors (Eitan et al., 2017; Kidorf et al., 2016). In the current COVID-19 pandemic, there have been significant disruptions to daily life including restrictions on in-person contact which may cause other forms of social networks (i.e., online) to become more salient. Isolated individuals in particular may be more likely to engage online platforms as a source of social support, taking comfort in anonymity and the opportunity to share intimate details about themselves (Morahan-Martin and Schumacher, 2003).

In addition to social benefits, social media sites (e.g., Facebook, Twitter) provide useful epidemiologic data sources for tracking drug use trends (Kazemi et al., 2017). One popular social media platform is Reddit (www.reddit.com) where content is driven by Redditors (Reddit site members) who use alias user names, allowing for anonymity when discussing stigmatized behaviors (e.g., Brett et al., 2019; Sowles et al., 2017). The majority of Reddit content is in English, with nearly half of the content posted by people who reside in the U.S. (Pew Research Center, 2019). Reddit is used by approximately 11 % of the population in the U.S. and is most popular among males aged 18–29 years (Pew Research Center, 2019). Moreover, because of Reddit’s unique community forums (‘subreddits’), which include voting for popular topics to create ‘trends’ and the ability for users to engage in long conversations over time (‘threads’), it is a useful platform for real-time insight into the patterns, opinions, and experiences of particular groups and populations (Sharma et al., 2017). Reddit may be particularly useful for studying stigmatized and/or marginalized populations, such as PWUD, (Pandrekar et al., 2018; Sharma et al., 2017) since unlike Facebook or Twitter, it provides an anonymous forum that allows more open sharing with others who engage in similar behaviors on theme-specific subreddits (Sharma et al., 2017). Reddit data provide a robust source of information regarding substance use behaviors. Reddit has recently been used in a variety of studies on substance use including a content analysis of JUUL discussions (Brett et al., 2019); an examination of people who use opioids transitions from drug use to addiction (Lu et al., 2019); and an analysis of how social support and networking can aid peoples’ efforts to quit Cannabis use (Sowles et al., 2017). These first-person narratives are particularly insightful when seeking real-time data, such as during the COVID-19 pandemic (Gozzi et al., 2020; Low et al., 2020).

This paper uses data obtained from Reddit, a social media platform used by many PWUD to engage in drug-specific discussions, to examine the impact of COVID-19 on the social networks and social processes of people who use opioids. Scholars have previously used a Big Events framework (Friedman et al., 2009) to explore how socially disruptive events change drug environments and behaviors. Considered in the context of COVID-19, the theory of Big Events suggests that COVID-19 affects people’s daily lives, including differentially limiting communication with social network members and access to resources such as drugs and/or treatment. Big Events cause disruptions that have previously been identified to change social networks in ways that may influence drug-related harms (Friedman et al., 2009). For example, the financial crisis in Greece was hypothesized to be related to the increased rate of HIV among PWUD (Nikolopoulos et al., 2015). Many PWUD lost their jobs and subsequently housing. When new individuals entered the central city as homeless, they began to mix with previously homeless PWUD, and an increased sharing of injection equipment is proposed to have occurred due to the expansion of social networks (Nikolopoulos et al., 2015). The COVID-19 pandemic may be unique in that social distancing has limited social networks and in-person contact. The current research aims to understand how the social networks of PWUD have been affected during COVID-19.

2. Methods

2.1. Data collection

Data for this study were collected from the social media forum, Reddit.com. Data included the main post and subsequent comments and thus can be thought of as a conversation. Data were collected from the two most popular opioid subreddits, “r/Opiates” and “r/OpiatesRecovery.” Popularity was determined by the number of Redditors subscribed to the subreddit. Data were extracted using PRAW, an automated program that uses Python to extract Reddit posts and comments. The 1,000 most recent posts and corresponding comments from each subreddit at the time of data extraction were collected for a total sample of 2,000 posts. Extraction of data by recency resulted in a timeframe of March 5, 2020, to May 13, 2020. This study was considered non-human subjects research, exempt from IRB review. However, to protect the anonymity of post authors the Reddit usernames were removed, and direct quotes were slightly altered to reduce the risk of searchability and identifiability of posts (Ayers et al., 2018; Wilkinson and Thelwall, 2011).

The coding process was part of a larger project aimed at understanding how persons who use opioids were coping during COVID-19. A team of nine analysts experienced in qualitative coding received a series of training (developed by the first and senior author) specific to opioid use, slang, and Reddit culture. The training occurred over four one-hour sessions during regularly scheduled lab meetings. The purpose of the training was to provide an overview of opioid use, introduce common slang terms for opioids and other drugs, and provide an overview to Reddit as a social media forum. The analysts first reviewed all 2,000 posts for relevance to opioid use and COVID-19. Relevance was determined using a list of key terms developed by the research team including “coronavirus,” “COVID-19″ “quarantine” “social distancing” “shutdown” “pandemic” as well as any other related terms or concepts that analysts understood to be referring to the pandemic. For purposes of identifying COVID-relevant content, only main posts (i.e., the first post in a thread) were reviewed rather than all of the subsequent comments. Fifteen percent (N = 300) of the posts were related to COVID-19 and included in the final sample for analysis. The final sample of 300 COVID-19 related posts and their comments were coded by analysts using a hybrid inductive-deductive approach (Fereday and Muir-Cochrane, 2006) using Atlas.ti software. A codebook was created a priori by the research team (i.e., deductive approach) using study themes of interest related to the intersection of opioid use and COVID-19 circumstances (e.g., withdrawal, increased fear or anxiety, COVID-related closure). An initial 10 % (n = 30) of posts and comments were coded by all analysts and discussed to assess discrepancies and ensure content was covered by the codebook. Additions to the codebook were made based on common themes found during this meeting (i.e., inductive approach), and any discrepancies in coding were resolved. The final codebook had 44 codes. The remaining posts and comments were then coded.

2.2. Analysis

A thematic analysis of coded content was completed by the first author, guided by the Big Events framework. Seventeen of the 44 codes were selected as relevant to the current analysis. Codes were excluded if they were specific to other research questions (e.g., treatment focused) and if the initial review of content revealed the data was not relevant to the social theme of the current analysis. The codes are detailed in Table 1 . Specifically, codes were examined to thematically consider them within possible mechanisms of disruption to social networks and daily lives. Additionally, the thematic analysis examined coded data to determine social norms and forms of mutual aid shared among Redditors during COVID-19. The themes and associated content were discussed with the research team and any conflicts were resolved. Three themes were identified:1) changes in social networks, 2) changes in daily lives, and 3) social norms and mutual aid.

Table 1.

Excerpt from Codebook, Codes Examined for Thematic Analysis.

Code	Code Description
Asking for advice/support/information	Asking other users for advice/support/information related to issues or questions that arise during COVID19
Challenges of remote work	Analyst-generated
Changes in access to social networks	Discussing changes (increase or decrease) in access to social networks, support systems due to COVID-19 circumstances
Changes in risk behaviors	Discussing changes in drug use risk behaviors tied to COVID-19-related circumstances
Coping strategies for sobriety	Discussing self-strategies to reduce drug use or maintain sobriety during COVID-19
COVID-related infection/illness	Discussing issues related to coronavirus infection/covid-19 illness and how it has affected them and/or family or loved ones
COVID-related job/income loss	Discussing issues related to job loss due to COVID-19 related closures/changes
Discussing new ideas	Discussing or sharing ideas or thoughts related to issues or questions that arise during COVID19
Engaging in social support via online platforms	Discussing experiences of seeking/engaging in social support online as a way of getting through difficult times of COVID-19
General difficulty of COVID-19 pandemic	Analyst-generated
Helping Others	Discussing actions of helping/providing assistance to others during challenging times of COVID-19
Increased fear or anxiety	Discussing negative emotions of fear/anxiety related to current circumstances
Offering advice/support/information	Offering advice/support/information related to issues or questions that arise during COVID19
Social Distancing	Discussing practices of social distancing to reduce exposure risk from coronavirus
Stream of consciousness/venting	Sharing experiences/feelings related to current circumstances or struggles with others
Triggers for use/cravings	Discussing issues related to contact with past experiences, reminders of using drugs, cravings, etc.
Using quarantine as an opportunity to get sober	Analyst-generated
Withdrawal	Discussing experiences of withdrawal tied to COVID-19-related circumstances

3. Results

Results indicated the COVID-19 pandemic created changes in social networks and the daily lives of people who use opioids. As a result, individuals came to Reddit to share how they were adapting to such changes. As summarized in Table 2 , 8.3 % of posts and/or comments were relevant to a discussion of social networks changing and 24 % discussed changes to daily life as a result of COVID-19. The majority of content was related to social norms and mutual aid such that Redditors in 57.7 % of posts and comments offered advice or support and in 33 % of content Redditors sought advice and/or support. Selected illustrative quotes of the key themes are shared below. The influence of each of these factors on each other was also observed and is discussed.

Table 2.

Prevalence of themes in final sample of Reddit posts (n = 300).

Theme	Prevalence N(%)
Change in social networks	25 (8.3)
Change in daily life	72 (24.0)
Social norms and mutual aid
Offering advice and/or support	173 (57.7)
Asking for advice and/or support	99 (33.0)

Note: Themes are not mutually exclusive. Final sample included 300 Reddit posts and subsequent comments, which could be coded for multiple codes and themes.

3.1. Changes in social networks

The large disruption to routine caused by COVID-19 shifted the daily social networks of persons globally and was observed on Reddit. Several people discussed how their social networks narrowed during quarantine situations, and that this put their opioid use at risk of becoming known. Quarantine situations forced many individuals to stop using opioids. Consequently, some had to hide their withdrawal symptoms from family members with whom they were quarantined that were not aware of their opioid use, as was the case for the following two Redditors:

“I'm now seventeen days clean from everything cold turkey… And I did it without my partner knowing. Even in Quarantine. The day before [I quit] we had chicken for dinner. So I blamed [withdrawal] on food poisoning. That helped [to] explain the diarrhea, and feeling sick. Also said I had a mild body flu. By day eight I was starting to feel human. Meaning the physical symptoms were going away.”

“I was recently laid off due to COVID and had to move back home with my mom and stepdad (stepdad has been sober twenty-seven years and mom is a daily AAer) but they’d throw me on the streets if they found out I relapsed and I can’t lose my cats or be homeless- so I am not ready to face that consequence which is why I cannot go to a detox facility or tell them the truth- at least not right now. I can’t bear to hurt my mom like that and do not want her knowing I am not doing well. I really hope my doctor will call me in some clonodine or gabapentin.”

COVID-19 caused significant changes in the opioid use habits of many Redditors when social networks changed. In some cases, these issues were compounded by the individuals’ need to maintain responsibilities such as the care of pets or maintenance of housing. These quotes also illustrate the bidirectional relationship between changes to daily life and changes in social networks (job loss causing an individual to move in with parents, leading to a change in drug use).

For some, Reddit was a new social network accessed during COVID-19 due to their desire to use the ‘downtime’ and isolation of quarantine to cut back on their opioid use. In this data, it was only known if Redditors were new when they signaled (e.g., “I decided to make my first post here, maybe it will help someone…”). New Redditors appeared to be welcomed into the community, as opposed to being seen as outsiders.

3.2. Changes in daily life

Redditors shared the significant disruption to their daily lives as a result of COVID-19 lockdowns and closures. As illustrated above, changes to their social networks caused a change in their daily life (e.g., disrupted drug use), and vice versa. Others discussed having to stop their drug use due to COVID-related disruption in income causing an end to their supply:

“Then this covid-19 shit happened and I lost my job. Used up whatever money I had left on OxyContin until I couldn't afford it. That is when I realized how bad I fucked up. The first three days were pure hell. The usual [withdrawal] symptoms.”

For many, the forced downtime due to lockdowns created an interest in treatment options and the desire to abandon opioid use. Some even saw the situation as advantageous for dealing with the effects of withdrawal:

“So I have been trying to get sober for about a year, I’ve gone through withdrawals more times than I can count. But I thought quarantine would be the perfect time to get clean. Maybe it [has been] three weeks, used, and now I am a week from when I used.”

“Anyway, as insensitive as it sounds, corona plopped in my lap at a perfect time. It gave me the perfect opportunity to detox and start recovering without any real physical responsibility.”

While this positive sentiment was echoed more in treatment-focused posts, many were uncomfortable with the lack of structure and isolation caused by lockdowns. Individuals also shared how lack of work, in-person peer-support meetings, schedule, and routine led to a return to substance use or increase in craving.

“My whole recovery was structured around my work routine and my narcotics anonymous meetings, both of which are out the window now…”

“I was feeling confident and then the pandemic hit. Now I think about opiates all the time again because I can't successfully distract myself. I am having dreams about them again, when I thought I was done with those.”

Individuals expressed significant frustrations and concerns caused by the COVID-19 lockdowns (e.g., economic turmoil, job loss, isolation). These challenges were exacerbated by opioid withdrawal:

“I am financially ruined, pretty much, I have lost all my usual face to face contact and live alone, and I am going through opiate withdrawal, I know I'm going to feel less able to handle stress because of that but for fucks sake will some people just give me a break for a little while. I am just trying to get through one hour at a time while my neurotransmitter system is imploding from within.”

The above quote also illustrates how Reddit provided a space for discussion of changes to the body. Not only were individuals faced with disruption to the more tangible moments of daily life, but they shared the significant changes to their physical state.

3.3. Social norms & mutual aid

On both subreddits, gratitude toward others appeared as a frequent theme. Such examples include Redditors stating they were thankful for advice or thanking others for reading the post (e.g., “thanks in advance” “thank you for listening” “thank you for reading my story”). Redditors also provided each other with robust social support. There were offers to continue conversations in private messages (e.g., “Feel free to message me if I can be of help”), encouragement of new or continued access to treatment (e.g., “I'm proud of you for being clean right now. Keep it up!”), and the overall idea that the person posting is not alone (e.g., “We got this man, I hope tomorrow is a better day”). Redditors were able to connect with individuals going through similar experiences, most often a collectivity around shared experiences of withdrawals or embracing remission, and relying on each other during difficult times as exemplified by this Redditor:

“wow.. you are literally speaking straight from my mind. I am in the exact same boat. I am terrified. at 14 h without and already feel off you can fucking do this though - what are you doing to keep yourself accountable? to stay clean? What is helping pass the time? let’s do this together. fuck this”

During this unprecedented time, Redditors used the platform to seek advice on unwanted changes to their opioid use such as having to use a different drug supply because of COVID-19, and advice on both illicit and prescription drug access and over the counter drugs used to manage withdrawal such as loperamide and kratom (e.g., “Damn loperamide have become hard/expensive to find….What are you doing about it?”). They had questions regarding new reactions to supply (e.g., new side effects from different opioids) and concerns about the adulteration of drugs. In the excerpt below, one Redditor sought advice on why pills were no longer having the same effect and concerns if they were adulterated or counterfeit:

“Have these pills lost their magic? Is my run over? But...how could my tolerance grow so much if lately I’ve only been doing them on occasion? Are they pressed? If so, with what do you think? Thank you for reading, those of you who did. Much love n peace.”

Redditors also had many questions related to the suddenly reduced access to opioids – either from illicit markets or maintenance-based treatment programs. They asked about where they should get their medications for opioid use disorder when clinics suddenly closed, how to cope with cravings, advice on tapering, and recommended medications to make it through the withdrawal period. Redditors tended to frame their situations, including their likelihood of succeeding in attempts at drug cessation, through individual-centric ideologies such as willpower and prior experience and focused less on how structural forces, like government policies, affected their situations and outcomes.

“Any advice besides keeping busy? Should I look into vivitrol?”

“IF I HAVE THE WILLPOWER, can I taper and get off this stuff, and if I go slow enough will it be "relatively" painless? I’ve had withdrawals many times, and it’s bad, just not off THIS shit for that long… Any advice I would appreciate-like a taper schedule…”

They turned to each other for advice on how to stay sober through robust explanations of their struggles and in simply stated terms such as this post, “How to stay clean in these coronavirus times?” Advice about withdrawal included seeking reassurance on how to differentiate withdrawal symptoms from COVID-19 symptoms:

“I just do not want there to be a point in time to where I’m feeling smacked into the ground from detoxing. Which I know I will but then possible maybe feeling a bit different cause of some of these medications I have? I do not want to confuse some of this shit with possibly being sick with this damn virus.”

They also used each other as sources of informal knowledge sharing on where to access on-line peer-support meetings, which meetings others would recommend, and how to navigate the in-person processes of peer-recovery in the new remote environment.

“With all the meetings on zoom now i was wondering if any of you all had tips on how to stay sober during COVID as well as how to get a sponsor in these trying times. thank you in advance”

Redditors participated in an abundance of mutual aid during this time. They shared unemployment benefits information, remote employment opportunities, online recovery meeting information, recommended taper schedules for dealing with the effects of withdrawal at home, medication support for withdrawal, and advice on how to navigate the health-system during this time (e.g., how to request take home from your doctor). Only one post encouraged that others obtain naloxone, and the dangers of withdrawal in isolation were not explicitly discussed. Redditors also shared medication options, telemedicine rehabilitation programs, and advice on telemedicine more broadly:

“Plenty of doctors are doing the "telemedicine" thing now and a lot are taking new patients due to the expected uptick in mental health issues during the pandemic. You should be able to find a provider that takes your insurance in your area by going thru your insurances website portal thing. If you do not have insurance, I have never personally tried them but I have heard good things about some of those therapy apps like [redacted]. Developing healthier coping mechanisms, and eventually figuring out the root reasons for your addiction, are essential in recovery and the former is even more essential in times like this.”

They shared ways to stay engaged and busy, suggesting specific video games, sharing music, hobbies, recipes, and exercise recommendations including preferred yoga videos, encouraging each other to go for walks, and preferred meditation phone apps. For example, this Redditor shared tips on avoiding cravings and staying in remission:

“In terms of tips obviously I’m not nearly as far along as you, but I think a few things that have kept me “sane” have been exercise - if you have a rowing machine or bike in your home, or if you can at least take a jog outside (I think it should be warmer today). I find part of the problem with quarantine is being inside all day and at least [going] outside gives some structure and helps feel more like a routine.”

Finally, there was a common perception that sharing one’s struggles was helpful. Several provided the narrative that “maybe my story will help someone.” In this way, simply sharing about one’s struggles was a form of mutual aid and assistance:

“Thanks to everyone who contributes to the subreddit no matter where you are at in your recovery process. By asking for help and sharing your struggles, you are helping other people like me.”

4. Discussion

The current study examined the impact of COVID-19 on the social networks and social processes of persons who use opioids by examining first-person narratives on the public social media platform Reddit. Thematic analysis indicated that when COVID-19 disrupted social networks and daily life, Reddit provided an important source of social support during the pandemic for persons who use opioids. This research adds to previous studies that found that Reddit provides an important source of social support for PWUD (D’Agostino et al., 2017; Sowles et al., 2017; Wombacher et al., 2020). The anonymous forum provided a safe space where Redditors could openly discuss their opioid behavior in a way not possible through their in-person social networks such as family members or medical providers. This safe space became especially salient during COVID-19 when many faced significant changes to their daily life and subsequently their social networks.

Previous theory and measure development using the Big Events framework has pointed to the importance of changes in social networks, life conditions, and social norms as influencing the lives of people who use drugs, including engagement in risk behaviors and helping behaviors (Friedman et al., 2009, 2020a,b; Nikolopoulos et al., 2015; Pouget et al., 2016; Vasylyeva et al., 2020). For example, following Hurricane Sandy, people who inject drugs engaged in a variety of community support efforts, such as helping others obtain necessities and helping other PWUD to avoid withdrawal (Pouget et al., 2015). Similarly, the Redditors in the current study were unselfish and forthcoming in their social support. These ‘intraventions’ in which members of a subculture, such as PWUD, provide support and offer suggestions to other members about health or related issues take place frequently and are part of the process by which subcultural social norms are formed and maintained (Friedman et al., 2007, 2004; Mateu-Gelabert et al., 2008). Previous research of Reddit found the most significant form of social support to be sharing through personal experiences (D’Agostino et al., 2017). A common element of peer-recovery groups, sharing one’s personal experience has been found to have profound benefits (Niederhoffer and Pennebaker, 2009). Reddit appears to provide many of the same components- connectedness, giving through sharing- that are attributed to the success of recovery in groups such as Narcotics Anonymous (Dekkers et al., 2020). Online forums such as Reddit provide benefits to individuals with stigmatized disorders or behaviors, but these communities may be inaccessible to many rural, older, and low socioeconomic PWUD who may be less likely to have internet access or be less familiar with Reddit and other online support platforms (Anderson, 2018; White and Dorman, 2001). In consideration of prior research, results suggest that incorporating online access as a component of recovery resources and the thoughtful use of social media to provide psychosocial support interventions would be beneficial for PWUD.

In the current study, some Redditors report entering remission due to 'perfect timing’ created by the suspension of social obligations that COVID-19 created, while others were forced into withdrawals due to changes in their daily lives and social networks. For those who experienced withdrawal during COVID-19 lockdowns or due to unemployment, the social support of the Reddit community appeared to have an important role in their remission. Drug cessation often involves a reduction in the number of active PWUD in one’s social network (Bohnert et al., 2009; Buchanan and Latkin, 2008). However, the online forum of Reddit creates an environment where individuals can seek out recovery or remission-supportive networks (D’Agostino et al., 2017; Sowles et al., 2017). Comparatively, undesired, or forced reductions in opioid use can dramatically increase subsequent risk behavior (Rafful et al., 2018; Wegman et al., 2017; Werb et al., 2016). Moreover, withdrawal from opioids can be quite severe, particularly in the first few days, and include symptoms such as tremors, vomiting, insomnia, and anxiety (Kosten and Baxter, 2019). When the use of opioids has escalated to that of an opioid use disorder and withdrawal would occur, avoidance of withdrawal is often the reason for sustained and return to opioid use (Cicero and Ellis, 2017). As many Redditors described isolation or hidden opioid use, this self-managed withdrawal is particularly concerning, as a return to use after a period of abstinence would place them at increased risk of overdose during a period when they may have no one to administer naloxone if necessary. Early data from the COVID-19 crisis indicates that opioid overdoses are increasing (Katz et al., 2020; Slavova et al., 2020), and the Reddit conversations in this study were absent of overdose safety or encouragement of overdose preparedness (e.g., naloxone). Expansion of social initiatives such as the “Never Use Alone” hotline are critical during crises that create isolation such as COVID-19. However, this research did not track specific Redditors over time so insights to influxes in risk behavior are unknown.

The current analysis was guided by the Big Events framework and indicated in addition to robust social support, the COVID-19 pandemic has changed the social networks and daily lives of persons who use opioids. A bidirectional relationship between these factors was also apparent in the posts. Some individuals reported job loss, forcing them to quarantine with individuals from whom they had to hide their active drug use. The most robust theme of social support and mutual aid was found in previous research using the Big Events framework (Pouget et al., 2015). In the current research, the themes of changes to social networks and daily life were not as prevalent as may have been expected. The lower prevalence of these themes is likely due to the cross-sectional nature of the data that relied on overt statements by Redditors. Alternatively, in the Big Events framework changes to daily life and social networks are causal pathways that result in more concretely observed behaviors (e.g., drug use behaviors) and these themes may be more difficult to observe due to their implicit nature. Much of prior Big Events research has found changes in networks and norms to create susceptibility to drug-related harms (e.g., increase in HIV risk behaviors; Friedman et al., 2009; Hankins et al., 2002; Mackey and Strathdee, 2015). Previous events analyzed using this framework include economic and political crises (e.g., Argentina, Hungary, Greece) and found increased infectious disease transmission through causal pathways such as changes in drug-use behaviors and disruption to treatment (Friedman et al., 2009; Mackey and Strathdee, 2015). The COVID-19 pandemic is a unique big event that has created disruptions to social networks and limitations in face-to-face contact. It may be too early to see such community-level changes such as HIV-transmission, or other community-level factors, such as overdose, may be more applicable to a crisis that creates isolation.

4.1. Strengths and limitations

The current research responded to an urgent, real-time need to understand the social networks and social processes of persons who use opioids during an unprecedented public health crisis. Some limitations should be considered, however. Reddit is mostly engaged by younger men in the U.S. (Clement, 2020; Pew Research Center, 2019), and they may represent a subsample of persons who use opioids who are already prone to seek social online engagement. Demographics, including location and substance use history, of Redditors were not available. The Big Events framework that guided this analysis suggest big events create network changes, but the cross-sectional data and the fact that Redditors were not tracked temporally makes it difficult to suggest changes in a domain unless overtly stated (e.g., ‘I lost my job’ indicating a change in daily life). Inclusion criteria for the current sample included that posts must topically refer to COVID-19 and opioid use. This criterion may have resulted in posts from Redditors who were more likely to use COVID-19 related changes as a turning point in opioid use behaviors, as compared to individuals who were undeterred by COVID-19 and more likely to remain active in use and should be considered within that caveat.

4.2. Conclusions

Our analyses suggest that Reddit offered a robust platform for social support and mutual aid during a historically difficult period. Social support spanned current drug use to remission and daily life struggles during the pandemic. This level of social support would not likely have been possible in social crises that occurred before the widespread availability of internet access. Other big events and other social media sites will likely have different findings. However, the provision of internet access through WiFi or a shared computer at harm-reduction agencies can provide a resource to online support communities such as Reddit. Further, agencies and researchers working with PWUD should consider the utility of peer-based social media delivered interventions.

Contributors

A.B. performed the thematic analysis and led the writing of the article. D.F., N.K., S.F., and M.B. contributed to the writing, editing, and critical review of the article. J.A. oversaw data collection including providing data management and oversight of coders. All authors approved the final version submitted for publication.

Role of funding sources

Funding acknowledgments: This work was supported by the National Institutes of Health R25DA037190 (AB), 5T32DA007233-35 (DF), P30DA011041 (SF) and the Agency for Healthcare Research and Quality T32-HS026120-01 (AB). The opinions expressed are those of the authors.

Declaration of Competing Interest

The authors report no declarations of interest.